But firm diagnosis called essential before procedure is indicated

Action Points

Note that two meta-analyses suggest short-term benefits of tonsillectomy versus watchful waiting among children with recurrent throat infections.

Benefits were seen not only in the rate of recurrent infections but also in terms of sleep-apnea scales.

Tonsillectomy in children with recurrent throat infections and those with obstructive sleep disorders was linked with short-term improvements in health compared to medical management, researchers found in two separate analyses of published data.

In a systematic review, children with recurrent throat infections (defined as 3 or more throat infections in the previous 1 to 3 years) showed small improvements in throat infections, healthcare utilization, and quality of life measures, such as school absences, compared to "watchful waiting," reported Anna Morad, MD, of Vanderbilt University Medical Center, and colleagues.

And in a meta-analysis, a different group of researchers found that both apnea-hypopnea scores and sleep-related quality of life improved in children who had the procedure.

Recurrent Infections

Writing in Pediatrics, Morad and colleagues noted that previous systematic reviews had looked at adults and children together, while theirs wanted specifically to examine the effect of the procedure on children with recurrent throat infections.

Overall, they examined seven studies that addressed various health indicators of children who received tonsillectomies compared with children who did not have surgery. Two studies addressed the number of sore throat episodes, with an intention-to-treat analysis from a randomized trial finding that children who underwent tonsillectomy saw the number of sore throat episodes decreased by 3.5 over 2 years. Another randomized trial found that children who did not undergo tonsillectomy were 3.1 times more likely to test positive for group A streptococcus infection.

Healthcare utilization was also reduced following tonsillectomy as opposed to medical management. Two randomized trials examined the difference in healthcare visits between tonsillectomy and watchful waiting, with one trial finding that in the first post-surgical year, children with tonsillectomies had 1.74 episodes of sore throat or throat infection compared to 2.93 in the "control" group. A retrospective cohort study found a significant difference in visits to a clinician's office with 2.46 fewer visits in the first 1-3 years following surgery versus children who opted for medical management.

Several studies found that children who had tonsillectomies were associated with "fewer" missed days of school in the short term than the watchful waiting group, though the authors noted that these differences diminished over time.

Short-Term Sleep Outcomes

In the meta-analysis, researchers led by Sivakumar Chinnadurai, MD, of Vanderbilt University, examined 11 studies including five that looked specifically at obstructive sleep-disordered breathing outcomes. Three of these -- including various studies comprising the Childhood Adenotonsillectomy Trial (CHAT) -- were combined into a fixed-effects meta-analysis. These three studies showed that children who underwent tonsillectomy had a mean reduction (signifying improvement) of 4.81 points (95% CI -6.5 to -3.1) in the apnea-hypopnea index, which indicates the severity of sleep apnea as measured by the number of sleep disruptions.

Chinnadurai and colleagues noted that the change was significant, but may be "most clinically evident" in children with mild or moderate obstructive sleep-disordered breathing.

Four studies examined quality of life for children who underwent surgery versus those who did not, and found that outcomes were "consistently better," using such measures as the Modified Epworth Sleepiness Scale and the OSA-18. The authors noted that "children with tonsillectomy had significantly greater improvements in sleep quality" than the non-surgical group.

Three studies also addressed behavioral outcomes, such as anxiety and emotional lability. Notably, the CHAT trial found greater improvements in child behavior in the tonsillectomy group compared to the non-surgical group.

Chinnadurai's group advised that future studies need to "characterize patient populations completely," including the severity of their obstructive sleep-disordered breathing, to evaluate potential candidates for either surgery or watchful waiting.

Tonsillectomies have been in the news lately, with the recent case of the Detroit 9-year-old who died following the procedure.

"The major takeaway messages from these two studies is that you need to have a very objectively determined diagnosis before tonsillectomy surgery can be recommended," David Gozal, MD, of the University of Chicago told MedPage Today via email. Gozal was not involved with either study.

He recommended either "well-documented" throat infections exceeding three per year, or "a sleep study or equivalent test clearly confirming the presence of sleep-disordered breathing," as prerequisites before tonsillectomy should be considered for treating these conditions.

Although the risks of tonsillectomy are well-known, Gozal said only a small proportion of children get a sleep study prior to the procedure.

"When actual presence of obstructive sleep apnea is not confirmed by appropriate testing and when the severity is not established before surgery, there is the potential for a subset of high-risk patients to be subjected to the routine surgical pre-, intra -- and post-operative procedures, thereby placing them at risk for development of potentially preventable complications," he added.

Both studies were supported by the Agency for Healthcare Research and Quality.

All authors on both studies received funding from AHRQ grants.

One co-author on both studies disclosed salary support from NIH grants.

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